2013 Prior Authorization (PA) Criteria

Transcription

1 2013 Prior Authorization (PA) Criteria Certain drugs require prior authorization from EmblemHealth Medicare HMO/PPO Medicare Plans. This means that your doctor must contact us to get approval before prescribing the drug to you. If your doctor does not get prior approval, the drug may not be covered. This list also includes drugs that may be covered under Medicare Part B or Part D depending on how the drugs are used or administered. If your drug is on this list, your doctor should call us and to provide information describing the use and administration of the drug so we can advise on whether the drug will be covered. To see if your drug is on the list, refer to the table of contents below for the prior authorization criteria you are looking for, or refer to the index located at the end of this document for the medication you are looking for. TABLE OF CONTENTS ACTEMRA ACTEMRA ACTHAR H.P. ACTHAR ACTIMMUNE ACTIMMUNE ADCIRCA Updated: 06/2013 Y0026_ Approved 09/25/2012 Page 1 of 80 Group Health Incorporated (GHI), GHI HMO Select, Inc. (GHI HMO), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies, EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

2 ADCIRCA AFINITOR AFINITOR AVONEX AVONEX ADMINISTRATION PACK AVONEX B vs D - Medicare Part B versus Medicare Part D Coverage PA ABILIFY ACETYLCYSTEINE ACYCLOVIR SODIUM ADAGEN ADRIAMYCIN A-HYDROCORT ALBUTEROL SULFATE ALDURAZYME ALIMTA ALLOPURINOL SODIUM AMIFOSTINE AMIKACIN SULFATE AMINOPHYLLINE AMINOSYN II AMINOSYN M AMINOSYN AMINOSYN-HBC AMINOSYN-PF Page 2 of 80

3 AMIODARONE HCL AMPHOTERICIN B AMPICILLIN SODIUM AMPICILLIN-SULBACTAM ARALAST NP ARCALYST ASTRAMORPH-PF AVASTIN AVELOX IV AZASAN AZATHIOPRINE AZATHIOPRINE SODIUM AZITHROMYCIN BENLYSTA BENZTROPINE MESYLATE BICNU BLEOMYCIN SULFATE BUDESONIDE BUPRENORPHINE HCL BUSULFEX CALCITRIOL CAMPATH CANCIDAS CAPASTAT SULFATE CARBOPLATIN Page 3 of 80

4 CEFAZOLIN SODIUM CEFEPIME HCL CEFOTAXIME SODIUM CEFOXITIN CEFOXITIN SODIUM CEFTRIAXONE CEFUROXIME SODIUM CELLCEPT CEREZYME CHLORAMPHENICOL SOD SUCCINATE CHORIONIC GONADOTROPIN CIDOFOVIR CIMETIDINE CIMZIA CINRYZE CIPROFLOXACIN CIPROFLOXACIN-D5W CISPLATIN CLADRIBINE CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE-D5W CLINIMIX E CLINIMIX CLINISOL COLISTIMETHATE SODIUM Page 4 of 80

5 COSMEGEN CROMOLYN SODIUM CUBICIN CYCLOPHOSPHAMIDE CYCLOSPORINE CYCLOSPORINE MODIFIED CYKLOKAPRON CYTARABINE DACARBAZINE DAUNORUBICIN HCL DEPO-PROVERA DEXAMETHASONE SODIUM PHOSPHATE DEXRAZOXANE DIGOXIN DILTIAZEM HCL DIPHENHYDRAMINE HCL DOXIL DOXORUBICIN HCL DOXYCYCLINE HYCLATE DRONABINOL DURAMORPH ELAPRASE ELELYSO ELITEK ELSPAR Page 5 of 80

6 EMEND ENGERIX-B EPIRUBICIN HCL ERYTHROCIN LACTOBIONATE ESTRADIOL VALERATE ETOPOSIDE FABRAZYME FAMOTIDINE FASLODEX FLUCONAZOLE IN DEXTROSE FLUDARABINE PHOSPHATE FLUOROURACIL FLUPHENAZINE HCL FOMEPIZOLE FOSPHENYTOIN SODIUM FREAMINE III WITH ELECTROLYTES FREAMINE III GAMMAGARD LIQUID GAMUNEX-C GANCICLOVIR SODIUM GEMCITABINE HCL GEMZAR GENGRAF GENTAMICIN SULFATE GENTAMICIN SULFATE IN NS Page 6 of 80

7 GRANISETRON HCL GRANISOL HALOPERIDOL DECANOATE HALOPERIDOL LACTATE HEPARIN SODIUM HEPARIN SODIUM IN 0.45% NACL HEPARIN SODIUM IN 0.9% NACL HEPARIN SODIUM-D5W HEPATAMINE HEPATASOL HERCEPTIN HYDROMORPHONE HCL HYDROXYZINE HCL IDARUBICIN HCL IFEX IFOSFAMIDE IMIPENEM-CILASTATIN SODIUM INCRELEX INTRALIPID INTRALIPID INTRON A INVANZ INVEGA SUSTENNA IPRATROPIUM BROMIDE IPRATROPIUM-ALBUTEROL Page 7 of 80

8 IRINOTECAN HCL ISTODAX KADCYLA KANAMYCIN SULFATE KETOROLAC TROMETHAMINE LABETALOL HCL LEUCOVORIN CALCIUM LEVALBUTEROL CONCENTRATE LEVALBUTEROL HCL LEVETIRACETAM LEVOCARNITINE LEVOFLOXACIN LIDOCAINE HCL LIOTHYRONINE SODIUM LIPOSYN III LUPRON DEPOT LUPRON DEPOT-PED MELPHALAN HCL MEPERIDINE HCL MEROPENEM MESNA METHADONE HCL METHOTREXATE METHYLDOPATE HCL METHYLPREDNISOLONE ACETATE Page 8 of 80

9 METHYLPREDNISOLONE SOD SUCC METOCLOPRAMIDE HCL METOPROLOL TARTRATE MIACALCIN MITOMYCIN MITOXANTRONE HCL MOZOBIL MUSTARGEN MYCOPHENOLATE MOFETIL MYFORTIC MYOZYME NAFCILLIN SODIUM NAGLAZYME NALBUPHINE HCL NALOXONE HCL NEORAL NEPHRAMINE NEUMEGA NEXIUM I.V NITROGLYCERIN NOVAREL NULOJIX ONDANSETRON HCL ONDANSETRON ODT ONTAK Page 9 of 80

10 ORENCIA ORPHENADRINE CITRATE OXALIPLATIN PACLITAXEL PAMIDRONATE DISODIUM PENICILLIN G POTASSIUM PENICILLIN G SODIUM PENTOSTATIN PERFOROMIST PERJETA PHENYTOIN SODIUM PIPERACILLIN-TAZOBACTAM PREGNYL PREMARIN PREMASOL PREMASOL PRIMAXIN PROCALAMINE PROGRAF PROLEUKIN PROLIA PROMETHAZINE HCL PROPRANOLOL HCL PROSOL PULMOZYME Page 10 of 80

11 RANITIDINE HCL RAPAMUNE RECLAST RECOMBIVAX HB REMODULIN RHEUMATREX RIFAMPIN RISPERDAL CONSTA RITUXAN SANCUSO SANDIMMUNE SIMULECT SOLU-CORTEF SOMATULINE DEPOT SOMAVERT SULFAMETHOXAZOLE-TRIMETHOPRIM SYNRIBO TACROLIMUS TERBUTALINE SULFATE TESTOSTERONE CYPIONATE TESTOSTERONE ENANTHATE TETANUS DIPHTHERIA TOXOIDS TETANUS TOXOID ADSORBED TETANUS-DIPHTERIA-DECAVAC TOBI Page 11 of 80

12 TOBRAMYCIN SULFATE TOPOSAR TOPOTECAN HCL TPN ELECTROLYTES TRANEXAMIC ACID TRAVASOL TREANDA TRELSTAR TRISENOX TROPHAMINE VALPROATE SODIUM VANCOMYCIN HCL VELCADE VERAPAMIL HCL VFEND IV VINBLASTINE SULFATE VINCRISTINE SULFATE VINORELBINE TARTRATE VORAXAZE VORICONAZOLE VPRIV ZALTRAP ZEMPLAR ZOLEDRONIC ACID ZOMETA Page 12 of 80

13 ZORTRESS CIALIS CIALIS CIMZIA CIMZIA COPAXONE COPAXONE EPO PROCRIT EXTAVIA EXTAVIA GLEEVEC GLEEVEC GROWTH HORMONE NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX HRM EDITS ALPRAZOLAM ALPRAZOLAM ER ALPRAZOLAM ODT CARISOPRODOL CHLORZOXAZONE CLONAZEPAM CLORAZEPATE DIPOTASSIUM CYCLOBENZAPRINE HCL Page 13 of 80

14 CYPROHEPTADINE HCL DIAZEPAM DICYCLOMINE HCL DIPHENHYDRAMINE HCL DIPHENOXYLATE-ATROPINE DIPYRIDAMOLE ESTROPIPATE HYDROXYZINE HCL HYDROXYZINE PAMOATE LORAZEPAM LORAZEPAM INTENSOL METHOCARBAMOL ORPHENADRINE CITRATE ORPHENADRINE COMPOUND ORPHENADRINE COMPOUND FORTE OXAZEPAM PHENADOZ PROMETHAZINE HCL PROMETHAZINE VC PROMETHEGAN TEMAZEPAM TRANXENE T-TAB TRIMETHOBENZAMIDE HCL INFERGEN INFERGEN Page 14 of 80

15 KUVAN KUVAN LETAIRIS LETAIRIS LEUKINE LEUKINE NEUPOGEN NEUPOGEN NEXAVAR NEXAVAR OCTREOTIDE OCTREOTIDE ACETATE ONFI ONFI PEGASYS PEGASYS PROCLICK PEGASYS PEGINTRON PEGINTRON REDIPEN PEGINTRON POMALYST POMALYST REBIF REBIF REMICADE Page 15 of 80

16 REMICADE REVATIO REVATIO SILDENAFIL REVLIMID REVLIMID RIBAVIRIN REBETOL RIBAPAK RIBASPHERE RIBAVIRIN SABRIL SABRIL SANDOSTATIN LAR SANDOSTATIN LAR SPRYCEL SPRYCEL SUTENT SUTENT TARCEVA TARCEVA TARGRETIN TARGRETIN TASIGNA TASIGNA Page 16 of 80

17 THALOMID THALOMID THIORIDAZINE THIORIDAZINE HCL TRACLEER TRACLEER TYKERB TYKERB VIMPAT VIMPAT VOTRIENT VOTRIENT XALKORI XALKORI XOLAIR XOLAIR ZELBORAF ZELBORAF Page 17 of 80

18 ACTEMRA ACTEMRA Active infection (including TB). Concurrent therapy with other biologic agent(s). Screening for latent tuberculosis is required. If results are positive, patient must have completed treatment or must currently be receiving treatment for latent tuberculosis. Evaluate for HBV risk and initiate treatment if appropriate. Must have an inadequate response or intolerance/contraindication to one TNF [Tumor necrosis factor] antagonist therapy. Plan Year. For renewals, patient must have responded to Actemra therapy (e. g., condition improved or stabilized). Page 18 of 80

19 ACTHAR H.P. ACTHAR All FDA-approved indications not otherwise excluded from Part D. Use in patients with multiple sclerosis (MS) as pulse therapy on a monthly basis. MS [Multiple Sclerosis] exacerbation, history of corticosteroid use. Infantile spasms, prescribed by or in consultation with a neurologist or an epileptologist. MS [Multiple Sclerosis] exacerbation, prescribed by or in consultation with a neurologist or physician that specializes in the treatment of MS [Multiple Sclerosis]. Infantile spasms, 12 months. MS [Multiple Sclerosis] exacerbation, approve 1 month. For MS [Multiple Sclerosis] exacerbation, approve if the patient cannot use highdose IV corticosteroids because IV access is not possible or if the patient has tried highdose corticosteroids administered IV for an acute MS [Multiple Sclerosis] exacerbation and has experienced a severe or limiting adverse effect. Page 19 of 80

20 ACTIMMUNE ACTIMMUNE Plan Year. Page 20 of 80

21 ADCIRCA ADCIRCA Nitrate therapy. PAH [Pulmonary Arterial Hypertension] been confirmed by right heart catheterization. Plan Year. Page 21 of 80

22 AFINITOR AFINITOR Oncologist. Plan Year. Page 22 of 80

23 AVONEX AVONEX ADMINISTRATION PACK AVONEX Plan Year. Page 23 of 80

24 B VS D - MEDICARE PART B VERSUS MEDICARE PART D COVERAGE PA ABILIFY ACETYLCYSTEINE ACYCLOVIR SODIUM ADAGEN ADRIAMYCIN A-HYDROCORT ALBUTEROL SULFATE ALDURAZYME ALIMTA ALLOPURINOL SODIUM AMIFOSTINE AMIKACIN SULFATE AMINOPHYLLINE AMINOSYN II AMINOSYN M AMINOSYN AMINOSYN-HBC AMINOSYN-PF AMIODARONE HCL AMPHOTERICIN B AMPICILLIN SODIUM AMPICILLIN-SULBACTAM ARALAST NP ARCALYST ASTRAMORPH-PF AVASTIN AVELOX IV AZASAN AZATHIOPRINE AZATHIOPRINE SODIUM AZITHROMYCIN BENLYSTA BENZTROPINE MESYLATE BICNU BLEOMYCIN SULFATE BUDESONIDE BUPRENORPHINE HCL Page 24 of 80

25 BUSULFEX CALCITRIOL CAMPATH CANCIDAS CAPASTAT SULFATE CARBOPLATIN CEFAZOLIN SODIUM CEFEPIME HCL CEFOTAXIME SODIUM CEFOXITIN CEFOXITIN SODIUM CEFTRIAXONE CEFUROXIME SODIUM CELLCEPT CEREZYME CHLORAMPHENICOL SOD SUCCINATE CHORIONIC GONADOTROPIN CIDOFOVIR CIMETIDINE CIMZIA CINRYZE CIPROFLOXACIN CIPROFLOXACIN-D5W CISPLATIN CLADRIBINE CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE-D5W CLINIMIX E CLINIMIX CLINISOL COLISTIMETHATE SODIUM COSMEGEN CROMOLYN SODIUM CUBICIN CYCLOPHOSPHAMIDE CYCLOSPORINE CYCLOSPORINE MODIFIED CYKLOKAPRON CYTARABINE DACARBAZINE Page 25 of 80

26 DAUNORUBICIN HCL DEPO-PROVERA DEXAMETHASONE SODIUM PHOSPHATE DEXRAZOXANE DIGOXIN DILTIAZEM HCL DIPHENHYDRAMINE HCL DOXIL DOXORUBICIN HCL DOXYCYCLINE HYCLATE DRONABINOL DURAMORPH ELAPRASE ELELYSO ELITEK ELSPAR EMEND ENGERIX-B EPIRUBICIN HCL ERYTHROCIN LACTOBIONATE ESTRADIOL VALERATE ETOPOSIDE FABRAZYME FAMOTIDINE FASLODEX FLUCONAZOLE IN DEXTROSE FLUDARABINE PHOSPHATE FLUOROURACIL FLUPHENAZINE HCL FOMEPIZOLE FOSPHENYTOIN SODIUM FREAMINE III WITH ELECTROLYTES FREAMINE III GAMMAGARD LIQUID GAMUNEX-C GANCICLOVIR SODIUM GEMCITABINE HCL GEMZAR GENGRAF GENTAMICIN SULFATE Page 26 of 80

27 GENTAMICIN SULFATE IN NS GRANISETRON HCL GRANISOL HALOPERIDOL DECANOATE HALOPERIDOL LACTATE HEPARIN SODIUM HEPARIN SODIUM IN 0.45% NACL HEPARIN SODIUM IN 0.9% NACL HEPARIN SODIUM-D5W HEPATAMINE HEPATASOL HERCEPTIN HYDROMORPHONE HCL HYDROXYZINE HCL IDARUBICIN HCL IFEX IFOSFAMIDE IMIPENEM-CILASTATIN SODIUM INCRELEX INTRALIPID INTRALIPID INTRON A INVANZ INVEGA SUSTENNA IPRATROPIUM BROMIDE IPRATROPIUM-ALBUTEROL IRINOTECAN HCL ISTODAX KADCYLA KANAMYCIN SULFATE KETOROLAC TROMETHAMINE LABETALOL HCL LEUCOVORIN CALCIUM LEVALBUTEROL CONCENTRATE LEVALBUTEROL HCL LEVETIRACETAM LEVOCARNITINE LEVOFLOXACIN LIDOCAINE HCL LIOTHYRONINE SODIUM Page 27 of 80

28 LIPOSYN III LUPRON DEPOT LUPRON DEPOT-PED MELPHALAN HCL MEPERIDINE HCL MEROPENEM MESNA METHADONE HCL METHOTREXATE METHYLDOPATE HCL METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE SOD SUCC METOCLOPRAMIDE HCL METOPROLOL TARTRATE MIACALCIN MITOMYCIN MITOXANTRONE HCL MOZOBIL MUSTARGEN MYCOPHENOLATE MOFETIL MYFORTIC MYOZYME NAFCILLIN SODIUM NAGLAZYME NALBUPHINE HCL NALOXONE HCL NEORAL NEPHRAMINE NEUMEGA NEXIUM I.V. NITROGLYCERIN NOVAREL NULOJIX ONDANSETRON HCL ONDANSETRON ODT ONTAK ORENCIA ORPHENADRINE CITRATE OXALIPLATIN PACLITAXEL Page 28 of 80

29 PAMIDRONATE DISODIUM PENICILLIN G POTASSIUM PENICILLIN G SODIUM PENTOSTATIN PERFOROMIST PERJETA PHENYTOIN SODIUM PIPERACILLIN-TAZOBACTAM PREGNYL PREMARIN PREMASOL PREMASOL PRIMAXIN PROCALAMINE PROGRAF PROLEUKIN PROLIA PROMETHAZINE HCL PROPRANOLOL HCL PROSOL PULMOZYME RANITIDINE HCL RAPAMUNE RECLAST RECOMBIVAX HB REMODULIN RHEUMATREX RIFAMPIN RISPERDAL CONSTA RITUXAN SANCUSO SANDIMMUNE SIMULECT SOLU-CORTEF SOMATULINE DEPOT SOMAVERT SULFAMETHOXAZOLE-TRIMETHOPRIM SYNRIBO TACROLIMUS TERBUTALINE SULFATE Page 29 of 80

30 TESTOSTERONE CYPIONATE TESTOSTERONE ENANTHATE TETANUS DIPHTHERIA TOXOIDS TETANUS TOXOID ADSORBED TETANUS-DIPHTERIA-DECAVAC TOBI TOBRAMYCIN SULFATE TOPOSAR TOPOTECAN HCL TPN ELECTROLYTES TRANEXAMIC ACID TRAVASOL TREANDA TRELSTAR TRISENOX TROPHAMINE VALPROATE SODIUM VANCOMYCIN HCL VELCADE VERAPAMIL HCL VFEND IV VINBLASTINE SULFATE VINCRISTINE SULFATE VINORELBINE TARTRATE VORAXAZE VORICONAZOLE VPRIV ZALTRAP ZEMPLAR ZOLEDRONIC ACID ZOMETA ZORTRESS This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. Page 30 of 80

31 CIALIS CIALIS All FDA-approved indications not otherwise excluded from Part D. Indication for which tadalafil is being prescribed. Authorization will be for 12 months. Benign prostatic hyperplasia (BPH), after confirmation that tadalafil is being prescribed to treat the signs and symptoms of BPH [Benign Prostatic Hypertrophy] and not for the treatment of erectile dysfunction (ED) and after a trial of an alpha-1 blocker (eg, doxazosin [Cardura XL], terazosin, tamsulosin [Flomax], alfuzosin extendedrelease [UroXatral]) or 5 alpha reductase inhibitor (eg, finasteride, dutasteride [Avodart]). Page 31 of 80

32 CIMZIA CIMZIA Active infection (including TB). Concurrent therapy with other biologics. Screening for latent TB infection and assessment for Hep B risk. For positive latent TB, patient must have completed treatment or is currently receiving treatment for LTBI. HBV infection ruled out or treatment initiated for positive infection. Rheumatoid arthritis (RA) - Must have an inadequate response to either Enbrel or Humira and one of following: 1) inadequate response to methotrexate, 2) inadequate response to another nonbiologic DMARD [Disease-modifying antirheumatic drug] (e. g., leflunomide, hydroxychloroquine, sulfasalazine) if contraindicated or intolerant to MTX [methotrexate] or, 3) intolerance or contraindication to at least 2 nonbiologic DMARDs [Diseasemodifying antirheumatic drugs]. Crohn's Disease - Must have an inadequate response or contraindication/intolerance to at least one oral corticosteroid and Humira. 18 years of age and older. Initial: Plan Year for RA [Rheumatoid Arthritis], 3 months for Crohn's disease. Renewal: Plan Year. For re-authorization, patient's condition must have improved or stabilized. Page 32 of 80

33 COPAXONE COPAXONE Concurrent use of any of the following medications: Interferon-beta therapy (Avonex, Betaseron, Extavia, or Rebif), or mitoxantrone. Plan Year. Patients with previous use (12 or more months) of Copaxone must demonstrate one of the following clinical responses: decrease in the frequency of relapses, slowing of disease progression, diminished MRI lesions, OR patient is stable on therapy. Page 33 of 80

34 EPO PROCRIT Uncontrolled hypertension. For use in an anemic patient prior to surgery, the patient must also receive concomitant iron supplementation. For other indications, all of the following criteria are required: 1) The pretreatment Hgb is less than or equal to 10 g/dl for initial authorization. 2) The patient is receiving concomitant iron supplementation if iron stores are inadequate. 3) The Hgb is maintained at or below 12 g/dl once on therapy. 4) Once on therapy for 12 weeks, the hemoglobin must increase at least 1 g/dl in response to epoetin alfa. 12 weeks. Page 34 of 80

35 EXTAVIA EXTAVIA Concurrent use of any of the following medications: Interferon-beta therapy (Avonex, Betaseron, or Rebif), glatiramer acetate, or mitoxantrone. Plan Year. Patients with previous use (12 or more months) of Extavia must demonstrate one of the following clinical responses: decrease in the frequency of relapses, slowing of disease progression, MRI lesions have diminished with therapy, OR patient is stable on therapy. Page 35 of 80

36 GLEEVEC GLEEVEC Chronic myeloid leukemia (CML) and acute lymphoblastic leukemia (ALL) must be positive for the Philadelphia chromosome or BCR-ABL gene. For CML [Chronic Myeloid Leukemia], patient meets one of the following: 1) newly diagnosed, 2) resistance or intolerance to prior therapy, or 3) recurrence after stem cell transplant. For ALL, patient meets one of the following: 1) newly diagnosed and Gleevec is used in combination with chemotherapy, or 2) ALL is relapsed or refractory. For GIST, patient meets one of the following: 1) unresectable, recurrent, or metastatic disease, or 2) use of Gleevec for adjuvant therapy following resection, or 3) use of Gleevec for pre-operative therapy and patient is at risk for significant surgical morbidity. Plan Year. Page 36 of 80

37 GROWTH HORMONE NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX For pediatric GHD in neonate with hypoglycemia: patient has a randomly assessed GH [growth hormone] level less than 20 ng/ml, other causes of hypoglycemia have been ruled out, and other treatments have been ineffective. For all pediatric patients: patients have short stature or slow growth velocity and have been evaluated for other causes of growth failure. For pediatric GHD, patient has delayed bone age. For pediatric GHD without pituitary disease, patient failed 2 stimulation tests. For pediatric GHD with a pituitary or CNS disorder, patient has clinical evidence of GHD and low IGF- 1/IGFBP3. For TS and SHOX patients: diagnosis confirmed by genetic testing. For CRI patients: metabolic, endocrine and nutritional abnormalities have been treated or stabilized and patient has not had a kidney transplant. For SGA [Short child born small for gestational age]: patient has a low birth weight or length for gestational age. For ISS: pediatric GHD has been ruled out with one stimulation test. For adult GHD, patient was assessed for other causes of GHD-like symptoms. For adult GHD without pituitary disease, patient failed 2 stimulation tests. For adult GHD with at least 3 pituitary hormone deficiencies (PHD) or panhypopituitarism: have a low IGF-1. For adult GHD with less than 3 PHD, low IGF-1 and failed one stimulation test. For renewal for pediatric patients, growing more than 2 cm per year and for PWS only: improved body composition. For renewal for adult patients: patient has seen clinical improvement and IGF-1 will be monitored. For Turner syndrome and SGA [Short child born small for gestational age], 2 years of age and older. For Noonan syndrome and SHOX, 3 years of age and older. Endocrinologist, Pediatric Nephrologist, Gastroenterologist, Nutritional Support Specialist, Infectious Disease Specialist. Page 37 of 80

38 Plan Year. Page 38 of 80

39 HRM EDITS ALPRAZOLAM ALPRAZOLAM ER ALPRAZOLAM ODT CARISOPRODOL CHLORZOXAZONE CLONAZEPAM CLORAZEPATE DIPOTASSIUM CYCLOBENZAPRINE HCL CYPROHEPTADINE HCL DIAZEPAM DICYCLOMINE HCL DIPHENHYDRAMINE HCL DIPHENOXYLATE-ATROPINE DIPYRIDAMOLE ESTROPIPATE HYDROXYZINE HCL HYDROXYZINE PAMOATE LORAZEPAM LORAZEPAM INTENSOL METHOCARBAMOL ORPHENADRINE CITRATE ORPHENADRINE COMPOUND ORPHENADRINE COMPOUND FORTE OXAZEPAM PHENADOZ PROMETHAZINE HCL PROMETHAZINE VC PROMETHEGAN TEMAZEPAM TRANXENE T-TAB TRIMETHOBENZAMIDE HCL Page 39 of 80

40 Resticted for use in those less than 65 years of age. Plan Year. Page 40 of 80

41 INFERGEN INFERGEN Decompensated liver disease. Autoimmune hepatitis. Prior to initiating therapy, detectable levels of HCV RNA in the serum. For treatment nave, patient must have tried and had intolerance to pegylated interferon based treatment regimen. Allow Infergen monotherapy for treatment nave if patient has a contraindication or intolerance to ribavirin. For retreatment, must use in combination with ribavirin and must have tried and failed to respond to pegylated interferon and ribavirin. Allow only one time for retreatment. For Genotype 1 and 4: undetectable HCV RNA after 12 weeks of treatment OR at least 2 log decrease in HCV RNA after 12 weeks of therapy and undetectable HCV RNA after 24 weeks of treatment. ID specialist, gastroenterologist, or oncologist. 12 weeks to a total of 72 weeks depending on genotype and initial vs. renewal therapy. Monitored for evidence of depression. Page 41 of 80

42 KUVAN KUVAN Blood phenylalanine (Phe) levels. Pretreatment blood phenylalanine (Phe) levels greater than 10mg/dL if the patient is older than 12 years of age or greater than 6mg/dL if less than or equal to 12 years of age. Response to a therapeutic trial (greater than or equal to a 30% reduction in blood Phe levels) is required for long-term authorization. 1 month initial, plan year on renewal. Blood Phe levels should be checked after 1 week of therapy and periodically up to one month during a therapeutic trial. Page 42 of 80

43 LETAIRIS LETAIRIS Pregnancy. NYHA class II or III symptoms. PAH [Pulmonary Arterial Hypertension] been confirmed by right heart catheterization. Plan Year. UD or two appropriate contraceptive methods will be used for women of childbearing potential. Page 43 of 80

44 LEUKINE LEUKINE Administration within 24 hours preceding or following chemotherapy or radiotherapy, hypersensitivity to yeast-derived products. For prophylaxis of febrile neutropenia: use to increase the chemotherapy dose intensity or dose schedule above established regimens. For treatment of febrile neutropenia, when patient receives Neulasta during the current chemotherapy cycle. For AML [Acute Myeloid Lymphoma] only, excessive (greater than or equal to 10%) leukemic myeloid blasts in the bone marrow or peripheral blood. For patients with nonmyeloid malignancies receiving myelosuppressive chemotherapy: Leukine may be used for the prevention of chemotherapy-induced febrile neutropenia if the patient experienced febrile neutropenia with a prior chemotherapy cycle OR the patient is at high risk (greater than 20%) or intermediate risk (10-20%) for developing febrile neutropenia. Patients at low risk (less than 10%) for developing febrile neutropenia may also receive Leukine for prophylaxis if there is a significant risk for serious medical consequences due to febrile neutropenia and the intent of chemotherapy is to prolong survival or cure the disease. Leukine is allowable for the treatment of febrile neutropenia in patients who have received prophylaxis with Leukine (or Neupogen) OR in patients at risk for infection-related complications. All patients must receive baseline and regular monitoring of complete blood counts and platelet counts. 6 months. Page 44 of 80

45 Page 45 of 80

46 NEUPOGEN NEUPOGEN Administration within 24 hours preceding or following chemotherapy or radiotherapy, E coli hypersensitivity. For prophylaxis of febrile neutropenia: use to increase the chemotherapy dose intensity or dose schedule beyond established regimen. For treatment of febrile neutropenia, when patient receives Neulasta during the current chemotherapy cycle. For patients with nonmyeloid malignancies receiving myelosuppressive chemotherapy: Neupogen may be used for the prevention of chemotherapy-induced febrile neutropenia if the patient experienced febrile neutropenia with a prior chemotherapy cycle OR the patient is at high risk (greater than 20%) or intermediate risk (10-20%) for developing febrile neutropenia. Patients at low risk (less than 10%) for developing febrile neutropenia may receive Neupogen for prophylaxis if there is a significant risk for serious medical consequences due to febrile neutropenia and the intent of chemotherapy is to prolong survival or cure the disease. Neupogen is allowable for the treatment of febrile neutropenia in patients who have received prophylaxis with Neupogen (or Leukine) OR in patients at risk for infection-related complications. All patients must receive baseline and regular monitoring of complete blood counts and platelet counts. 6 months. Page 46 of 80

47 NEXAVAR NEXAVAR Combination with carboplatin and paclitaxel in patients with squamous cell lung cancer. Oncologist. Plan Year. Page 47 of 80

48 OCTREOTIDE OCTREOTIDE ACETATE Plan Year. Page 48 of 80

49 ONFI ONFI The patient will receive Onfi for the treatment of seizures associated with Lennox- Gastaut syndrome. 2 years of age and older. Plan Year. Page 49 of 80

50 PEGASYS PEGASYS PROCLICK PEGASYS Decompensated liver disease. Autoimmune hepatitis. Concomitant administration of didanosine with ribavirin in patients coinfected with HIV. HCV: Prior to initiating therapy, detectable levels of HCV RNA in the serum. For HCV treatment nave, allow Pegasys monotherapy if patient has a contraindication or intolerance to ribavirin. For HCV retreatment, must use in combination with ribavirin and must have nonresponse or relapse with prior HCV therapy. Allow only one time for retreatment with pegylated interferon and ribavirin. For Genotype 1 and 4: undetectable HCV RNA after 12 weeks of treatment OR at least 2 log decrease in HCV RNA after 12 weeks of therapy and undetectable HCV RNA after 24 weeks of treatment. HBV: Must have been HBsAg positive for at least 6 months and have persistent or intermittently elevated ALT greater than 2x ULN or liver biopsy showing chronic hepatitis with moderate to severe necroinflammation. For HBeAg positive, must have serum HBV- DNA greater than 100, 000 copies/ml or greater than 20, 000 IU/mL. For HBeAg negative, must have serum HBV-DNA greater than 10, 000 copies/ml or greater than 2, 000 IU/mL. ID specialist, Gastroenterologist, Oncologist. HCV:12 weeks to 72 weeks total depending on genotype and initial vs. renewal therapy. HBV:48 weeks. Monitor for evidence of depression. Page 50 of 80

51 PEGINTRON PEGINTRON REDIPEN PEGINTRON Decompensated liver disease. Autoimmune hepatitis. Concomitant administration of didanosine with ribavirin in patients coinfected with HIV. HCV: Prior to initiating therapy, detectable levels of HCV RNA in the serum. For HCV treatment nave, allow PegIntron monotherapy if patient has a contraindication or intolerance to ribavirin. For retreatment, must use in combination with ribavirin and must have nonresponse or relapse with prior HCV therapy. Allow only one time for retreatment with pegylated interferon and ribavirin. For Genotype 1 and 4: undetectable HCV RNA after 12 weeks of treatment OR at least 2 log decrease in HCV RNA after 12 weeks of therapy and undetectable HCV RNA after 24 weeks of treatment. ID specialist, Gastroenterologist, Oncologist. 12 weeks to a total 72 weeks depending on genotype and initial vs. renewal therapy. Monitor for evidence of depression. Page 51 of 80

52 POMALYST POMALYST Pregnancy. For active myeloma, patient meets the following: 1) Pomalyst is used after at least two prior therapies or as salvage therapy. 2) Pomalyst may be used with dexamethasone. For female patients of childbearing potential, pregnancy is excluded by 2 negative serum or urine pregnancy tests. For all patients, complete blood counts are monitored for hematologic toxicity while receiving Pomalyst. Plan Year. Male and female patients of child-bearing potential should be instructed on the importance of proper utilization of appropriate contraceptive methods for Pomalyst use. Patients should be monitored for signs and symptoms of thromboembolism. Page 52 of 80

53 REBIF REBIF Plan Year. Page 53 of 80

54 REMICADE REMICADE Active infection (including TB), concurrent use with other biologics, unstable moderate to severe HF (NYHA Functional Class III/IV). Screening for latent TB infection and assessment for Hep B risk. For positive latent TB, patient must have completed treatment or is currently receiving treatment for LTBI. HBV infection ruled out or treatment initiated for positive infection. Rheumatoid arthritis - An inadequate response or intolerance to Enbrel or Humira and one of the following: 1) inadequate response to methotrexate (MTX), 2) inadequate response to another nonbiologic DMARD [Disease-modifying antirheumatic drug] (e. g., leflunomide, hydroxychloroquine, sulfasalazine) if contraindicated or intolerant to MTX [methotrexate], 3) intolerance or contraindication to at least 2 nonbiologic DMARDs [Disease-modifying antirheumatic drugs]. Psoriatic arthritis with predominantly peripheral symptoms - Must meet both of the following: 1) have an inadequate response or intolerance to either Enbrel or Humira, and 2) have an inadequate response to at least an 8-week maximum tolerated dose trial of at least 1 nonbiologic DMARD [Disease-modifying antirheumatic drug] unless contraindicated or intolerant to such therapy. Psoriatic arthritis with predominantly axial symptoms and ankylosing spondylitis - Must have an inadequate response or intolerance/contraindication to at least 2 nonsteroidal anti-inflammatory drugs (NSAIDs). For plaque psoriasis - More than 10% BSA [Body surface area] affected or has crucial body areas (e. g., feet, hands, face) affected. An inadequate response to at least a 60-day trial of 2 conventional therapies (e. g., phototherapy, calcipotriene, MTX [methotrexate], acitretin) unless contraindicated or intolerant to such therapies. Crohn's disease - Must meet both of the following: 1) have an inadequate response to at least a 60-day trial of 1 conventional therapy (e. g., corticosteroids, sulfasalazine, azathioprine, mesalamine) unless contraindicated or intolerant to such therapy, and 2) have an inadequate response or intolerance to either Humira or Cimzia. Ulcerative colitis - An inadequate response to at least a 60-day trial of 2 conventional therapies (e. g., corticosteroids, mesalamine) unless contraindicated or intolerant to such therapies. Page 54 of 80

55 For plaque psoriasis, patient must be 18 years of age and older. Initial: 3 months for Crohn's disease and UC [Ulcerative colitis], plan year for all others. Renewal: plan year. For continuation of therapy, patient's condition must have improved or stabilized. Page 55 of 80

56 REVATIO REVATIO SILDENAFIL Nitrate therapy. Diagnosis of pulmonary arterial hypertension (PAH), (WHO Group 1). PAH [Pulmonary Arterial Hypertension] been confirmed by right heart catheterization. If patient is an infant, PAH [Pulmonary Arterial Hypertension] diagnosed by Doppler echocardiogram. The patient has had an inadequate response or intolerance to Adcirca. Plan Year. Page 56 of 80

57 REVLIMID REVLIMID Pregnancy. For active myeloma, patient meets one of the following: 1) Revlimid is used after at least one prior therapy or as salvage therapy. 2) Revlimid is used with dexamethasone as primary induction therapy or in combination with melphalan and prednisone in nontransplant candidates. 3) Revlimid is used as maintenance monotherapy following response to either stem cell transplant or primary induction therapy. For Low or Intermediate-1 Risk myelodysplastic syndrome (MDS): for those with 5q deletion, patients should have transfusion-dependent anemia or symptomatic anemia with clinically significant cytopenias. For those with non-5q deletion MDS [Myelodysplastic syndrome] and symptomatic anemia, patients should have failed to respond to epoetin alfa or darbepoetin or have a pretreatment serum erythropoietin levels greater than 500 mu/ml and a low probability of response to immunosuppressive therapy. For female patients of childbearing potential, pregnancy is excluded by 2 negative serum or urine pregnancy tests. For all patients, complete blood counts are monitored for hematologic toxicity while receiving Revlimid. Plan Year. Male and female patients of child-bearing potential should be instructed on the importance of proper utilization of appropriate contraceptive methods for Revlimid use. Patients should be monitored for signs and symptoms of thromboembolism. Page 57 of 80

58 RIBAVIRIN REBETOL RIBAPAK RIBASPHERE RIBAVIRIN Hemoglobin less than 8. 5 g/dl. Hemoglobinopathy. History of unstable heart disease. Creatinine clearance less than 50 ml/minute and unwilling to use modified dose of ribavirin. Pregnancy (self or partner). Unwilling to use effective contraception. Coadministration with didanosine in HIV coinfected patients. Prior to initiating therapy, detectable levels of HCV RNA in the serum. Must use in combination with interferon. For retreatment: patient must have nonresponse or relapse with prior HCV therapy. Allow only one time retreatment with pegylated interferon and ribavirin OR Infergen and ribavirin. For Genotype 1 and 4: undetectable HCV RNA after 12 weeks of treatment OR at least 2 log decrease in HCV RNA after 12 weeks of therapy and undetectable HCV RNA after 24 weeks of treatment. ID specialist, gastroenterologist, or oncologist. 12 weeks to a total 72 weeks depending on genotype and initial vs. renewal therapy. Patient has been instructed to practice effective contraception during therapy and for six months after stopping ribavirin therapy. Page 58 of 80

59 SABRIL SABRIL Patients with or at high risk of vision loss (except patients who have blindness). Patients using other medications associated with serious adverse ophthalmic effects such as retinopathy or glaucoma. Initial treatment infantile spasms, 1 month to 2 years. Initial treatment CPS, 16 years or older. Infantile spasms: initial 4 weeks, reauth 6 months. CPS: initial 3 months, reauth 12 months. Page 59 of 80

60 SANDOSTATIN LAR SANDOSTATIN LAR Patient received initial treatment with Sandostatin Injection (not the Depot form) for at least 2 weeks and treatment with Sandostatin Injection was effective and tolerable. Plan Year. Page 60 of 80

61 SPRYCEL SPRYCEL Acute lymphoblastic leukemia (ALL) and newly diagnosed chronic myeloid leukemia (CML) must be positive for the Philadelphia chromosome or BCR-ABL gene. For CML [Chronic Myeloid Leukemia], patient meets one of the following: 1) newly diagnosed in chronic phase, 2) resistance or intolerance to imatinib, or 3) relapse after stem cell transplant. For ALL, patient meets one of the following: 1) ALL is newly diagnosed and Sprycel is used in combination with chemotherapy, or 2) resistance or intolerance to prior therapy. 18 years of age and older. Plan Year. Page 61 of 80

62 SUTENT SUTENT Clinical manifestations of congestive heart failure. For gastrointestinal stromal tumor (GIST), disease progression while on an at least 30-day regimen of Gleevec or intolerance to Gleevec is required. LFT monitoring at initiation of therapy and throughout treatment. Oncologist. Plan Year. Therapy will be interrupted for serious hepatic adverse events and discontinued if serious hepatic adverse events do not resolve. Page 62 of 80

63 TARCEVA TARCEVA For 1st line therapy of locally advanced or metastatic NSCLC, patient should have a known active EGFR mutation or amplification of the EGFR gene. Plan Year. Page 63 of 80

64 TARGRETIN TARGRETIN Pregnancy. For capsules, patient meets one of the following: 1) cutaneous T cell lymphoma (includes mycosis fungoides [MF] and Sezary syndrome [SS]) refractory to prior systemic therapy, 2) advanced-stage MF/Sezary syndrome, 3) early-stage MF refractory/progressive to skin-directed therapy, or 4) early-stage MF with blood involvement or folliculotropic/large cell transformation. Plan Year. Patient has been instructed on the importance of and proper utilization of contraception. Page 64 of 80

65 TASIGNA TASIGNA Long QT syndrome, uncorrected electrolyte disorders (hypokalemia, hypomagnesemia). ECG obtained at baseline, 7-10 days after initiation of therapy and periodically throughout therapy. Newly diagnosed chronic myeloid leukemia (CML) must be positive for the Philadelphia chromosome or BCR-ABL gene. For CML [Chronic Myeloid Leukemia], patient meets one of the following: 1) newly diagnosed in chronic phase, 2) resistance to imatinib, 3) intolerance/toxicity to imatinib or dasatinib, or 4) relapse after stem cell transplant. 18 years of age and older. Plan Year. Patient has been instructed to avoid eating food 2 hours before and 1 hour after taking Tasigna. Concomitant use of drugs known to prolong the QT interval and strong CYP3A4 inhibitors should be avoided. Page 65 of 80

66 THALOMID THALOMID Pregnancy. For active myeloma, patient meets one of the following: 1) Thalomid is used as salvage or palliative therapy. 2) Thalomid is used for newly diagnosed disease or as primary induction therapy in combination with dexamethasone or in combination with melphalan and prednisone in nontransplant candidates. 3) Thalomid is used as maintenance monotherapy following response to either stem cell transplant or primary induction therapy. For female patients of childbearing potential, pregnancy is excluded by a negative pregnancy test. Plan Year. Patients are monitored for signs and symptoms of thromboembolism. Male and female patients of child-bearing potential are instructed on the importance of proper utilization of appropriate contraceptive methods. Page 66 of 80

67 THIORIDAZINE THIORIDAZINE HCL Plan Year. Page 67 of 80

68 TRACLEER TRACLEER AST/ALT level greater than 3 times upper limit of normal (ULN). Pregnancy. Concomitant use of cyclosporine A or glyburide. PAH [Pulmonary Arterial Hypertension] confirmed by right heart catheterization. NYHA Class II-IV symptoms. Plan Year. Female patients of childbearing potential must use more than one method of contraception concurrently. Page 68 of 80

69 TYKERB TYKERB Liver function tests must be monitored at baseline and every four to six weeks during therapy and as clinically indicated. In patients with severe hepatic impairment, Tykerb is used at a reduced dose. Plan Year. Page 69 of 80

70 VIMPAT VIMPAT A. The patient will receive Vimpat as an adjunctive anticonvulsant for the treatment of partial onset seizures. B. The patient had a previous or present trial/failure/contraindication to two or more of the following: carbamazepine, divalproex, ethosuximide, ethotoin, gabapentin, lamotrigine, levetiracetam, methsuximide, oxcarbazepine, phenytoin, phenobarbital, pregabalin, rufinamide, tiagabine, topiramate, valproic acid or zonisamide. 17 years of age and older. Plan Year. Page 70 of 80

71 VOTRIENT VOTRIENT Alanine transaminase (ALT) greater than 3 times the upper limit of normal (ULN) and bilirubin greater than 2 times the ULN. Oncologist. Plan Year. Page 71 of 80

72 XALKORI XALKORI All FDA-approved indications not otherwise excluded from Part D. Plus, patients with non-small cell lung cancer (NSCLC) already started on crizotinib. For the FDA-approved indication of NSCLC for patients new to therapy, ALK status required. Authorization will be for 12 months. NSCLC, patient new to therapy must be ALK-positive for approval. Page 72 of 80

73 XOLAIR XOLAIR 12 years of age and older. Pulmonologist, allergist or immunologist. Plan Year. To continue therapy, patients must demonstrate an improvement in asthma control with use of Xolair. Page 73 of 80

74 ZELBORAF ZELBORAF All FDA-approved indications not otherwise excluded from Part D. Plus, patients with melanoma already started on vemurafenib. For the FDA-approved indication of melanoma, for patients new to therapy, BRAFV600E status required. Authorization will be for 12 months. Melanoma, patient new to therapy must have BRAFV600E mutation for approval. Page 74 of 80

75 ABILIFY, 24 ACETYLCYSTEINE, 24 ACTEMRA, 18 ACTIMMUNE, 20 ACYCLOVIR SODIUM, 24 ADAGEN, 24 ADCIRCA, 21 ADRIAMYCIN, 24 AFINITOR, 22 A-HYDROCORT, 24 ALBUTEROL SULFATE, 24 ALDURAZYME, 24 ALIMTA, 24 ALLOPURINOL SODIUM, 24 ALPRAZOLAM, 39 ALPRAZOLAM ER, 39 ALPRAZOLAM ODT, 39 AMIFOSTINE, 24 AMIKACIN SULFATE, 24 AMINOPHYLLINE, 24 AMINOSYN II, 24 AMINOSYN M, 24 AMINOSYN, 24 AMINOSYN-HBC, 24 AMINOSYN-PF, 24 AMIODARONE HCL, 24 AMPHOTERICIN B, 24 AMPICILLIN SODIUM, 24 AMPICILLIN-SULBACTAM, 24 ARALAST NP, 24 ARCALYST, 24 ASTRAMORPH-PF, 24 AVASTIN, 24 AVELOX IV, 24 AVONEX ADMINISTRATION PACK, 23 AVONEX, 23 AZASAN, 24 AZATHIOPRINE, 24 AZATHIOPRINE SODIUM, 24 AZITHROMYCIN, 24 BENLYSTA, 24 BENZTROPINE MESYLATE, 24 BICNU, 24 BLEOMYCIN SULFATE, 24 BUDESONIDE, 24 BUPRENORPHINE HCL, 24 BUSULFEX, 25 CALCITRIOL, 25 CAMPATH, 25 CANCIDAS, 25 CAPASTAT SULFATE, 25 CARBOPLATIN, 25 CARISOPRODOL, 39 CEFAZOLIN SODIUM, 25 CEFEPIME HCL, 25 CEFOTAXIME SODIUM, 25 CEFOXITIN, 25 CEFOXITIN SODIUM, 25 CEFTRIAXONE, 25 CEFUROXIME SODIUM, 25 CELLCEPT, 25 CEREZYME, 25 CHLORAMPHENICOL SOD SUCCINATE, 25 CHLORZOXAZONE, 39 CHORIONIC GONADOTROPIN, 25 CIALIS, 31 CIDOFOVIR, 25 CIMETIDINE, 25 CIMZIA, 25, 32 CINRYZE, 25 CIPROFLOXACIN, 25 CIPROFLOXACIN-D5W, 25 CISPLATIN, 25 CLADRIBINE, 25 CLINDAMYCIN PHOSPHATE, 25 CLINDAMYCIN PHOSPHATE-D5W, 25 Page 75 of 80

76 CLINIMIX E, 25 CLINIMIX, 25 CLINISOL, 25 CLONAZEPAM, 39 CLORAZEPATE DIPOTASSIUM, 39 COLISTIMETHATE SODIUM, 25 COPAXONE, 33 COSMEGEN, 25 CROMOLYN SODIUM, 25 CUBICIN, 25 CYCLOBENZAPRINE HCL, 39 CYCLOPHOSPHAMIDE, 25 CYCLOSPORINE, 25 CYCLOSPORINE MODIFIED, 25 CYKLOKAPRON, 25 CYPROHEPTADINE HCL, 39 CYTARABINE, 25 DACARBAZINE, 25 DAUNORUBICIN HCL, 26 DEPO-PROVERA, 26 DEXAMETHASONE SODIUM PHOSPHATE, 26 DEXRAZOXANE, 26 DIAZEPAM, 39 DICYCLOMINE HCL, 39 DIGOXIN, 26 DILTIAZEM HCL, 26 DIPHENHYDRAMINE HCL, 26, 39 DIPHENOXYLATE-ATROPINE, 39 DIPYRIDAMOLE, 39 DOXIL, 26 DOXORUBICIN HCL, 26 DOXYCYCLINE HYCLATE, 26 DRONABINOL, 26 DURAMORPH, 26 ELAPRASE, 26 ELELYSO, 26 ELITEK, 26 ELSPAR, 26 EMEND, 26 ENGERIX-B, 26 EPIRUBICIN HCL, 26 ERYTHROCIN LACTOBIONATE, 26 ESTRADIOL VALERATE, 26 ESTROPIPATE, 39 ETOPOSIDE, 26 EXTAVIA, 35 FABRAZYME, 26 FAMOTIDINE, 26 FASLODEX, 26 FLUCONAZOLE IN DEXTROSE, 26 FLUDARABINE PHOSPHATE, 26 FLUOROURACIL, 26 FLUPHENAZINE HCL, 26 FOMEPIZOLE, 26 FOSPHENYTOIN SODIUM, 26 FREAMINE III WITH ELECTROLYTES, 26 FREAMINE III, 26 GAMMAGARD LIQUID, 26 GAMUNEX-C, 26 GANCICLOVIR SODIUM, 26 GEMCITABINE HCL, 26 GEMZAR, 26 GENGRAF, 26 GENTAMICIN SULFATE, 26 GENTAMICIN SULFATE IN NS, 27 GLEEVEC, 36 GRANISETRON HCL, 27 GRANISOL, 27 H.P. ACTHAR, 19 HALOPERIDOL DECANOATE, 27 HALOPERIDOL LACTATE, 27 HEPARIN SODIUM, 27 HEPARIN SODIUM IN 0.45% NACL, 27 HEPARIN SODIUM IN 0.9% NACL, 27 HEPARIN SODIUM-D5W, 27 HEPATAMINE, 27 HEPATASOL, 27 HERCEPTIN, 27 Page 76 of 80

77 HYDROMORPHONE HCL, 27 HYDROXYZINE HCL, 27, 39 HYDROXYZINE PAMOATE, 39 IDARUBICIN HCL, 27 IFEX, 27 IFOSFAMIDE, 27 IMIPENEM-CILASTATIN SODIUM, 27 INCRELEX, 27 INFERGEN, 41 INTRALIPID, 27 INTRALIPID, 27 INTRON A, 27 INVANZ, 27 INVEGA SUSTENNA, 27 IPRATROPIUM BROMIDE, 27 IPRATROPIUM-ALBUTEROL, 27 IRINOTECAN HCL, 27 ISTODAX, 27 KADCYLA, 27 KANAMYCIN SULFATE, 27 KETOROLAC TROMETHAMINE, 27 KUVAN, 42 LABETALOL HCL, 27 LETAIRIS, 43 LEUCOVORIN CALCIUM, 27 LEUKINE, 44 LEVALBUTEROL CONCENTRATE, 27 LEVALBUTEROL HCL, 27 LEVETIRACETAM, 27 LEVOCARNITINE, 27 LEVOFLOXACIN, 27 LIDOCAINE HCL, 27 LIOTHYRONINE SODIUM, 27 LIPOSYN III, 28 LORAZEPAM, 39 LORAZEPAM INTENSOL, 39 LUPRON DEPOT, 28 LUPRON DEPOT-PED, 28 MELPHALAN HCL, 28 MEPERIDINE HCL, 28 MEROPENEM, 28 MESNA, 28 METHADONE HCL, 28 METHOCARBAMOL, 39 METHOTREXATE, 28 METHYLDOPATE HCL, 28 METHYLPREDNISOLONE ACETATE, 28 METHYLPREDNISOLONE SOD SUCC, 28 METOCLOPRAMIDE HCL, 28 METOPROLOL TARTRATE, 28 MIACALCIN, 28 MITOMYCIN, 28 MITOXANTRONE HCL, 28 MOZOBIL, 28 MUSTARGEN, 28 MYCOPHENOLATE MOFETIL, 28 MYFORTIC, 28 MYOZYME, 28 NAFCILLIN SODIUM, 28 NAGLAZYME, 28 NALBUPHINE HCL, 28 NALOXONE HCL, 28 NEORAL, 28 NEPHRAMINE, 28 NEUMEGA, 28 NEUPOGEN, 46 NEXAVAR, 47 NEXIUM I.V., 28 NITROGLYCERIN, 28 NORDITROPIN FLEXPRO, 37 NORDITROPIN NORDIFLEX, 37 NOVAREL, 28 NULOJIX, 28 OCTREOTIDE ACETATE, 48 ONDANSETRON HCL, 28 ONDANSETRON ODT, 28 ONFI, 49 ONTAK, 28 Page 77 of 80

78 ORENCIA, 28 ORPHENADRINE CITRATE, 28, 39 ORPHENADRINE COMPOUND, 39 ORPHENADRINE COMPOUND FORTE, 39 OXALIPLATIN, 28 OXAZEPAM, 39 PACLITAXEL, 28 PAMIDRONATE DISODIUM, 29 PEGASYS PROCLICK, 50 PEGASYS, 50 PEGINTRON REDIPEN, 51 PEGINTRON, 51 PENICILLIN G POTASSIUM, 29 PENICILLIN G SODIUM, 29 PENTOSTATIN, 29 PERFOROMIST, 29 PERJETA, 29 PHENADOZ, 39 PHENYTOIN SODIUM, 29 PIPERACILLIN-TAZOBACTAM, 29 POMALYST, 52 PREGNYL, 29 PREMARIN, 29 PREMASOL, 29 PREMASOL, 29 PRIMAXIN, 29 PROCALAMINE, 29 PROCRIT, 34 PROGRAF, 29 PROLEUKIN, 29 PROLIA, 29 PROMETHAZINE HCL, 29, 39 PROMETHAZINE VC, 39 PROMETHEGAN, 39 PROPRANOLOL HCL, 29 PROSOL, 29 PULMOZYME, 29 RANITIDINE HCL, 29 RAPAMUNE, 29 REBETOL, 58 REBIF, 53 RECLAST, 29 RECOMBIVAX HB, 29 REMICADE, 54 REMODULIN, 29 REVATIO, 56 REVLIMID, 57 RHEUMATREX, 29 RIBAPAK, 58 RIBASPHERE, 58 RIBAVIRIN, 58 RIFAMPIN, 29 RISPERDAL CONSTA, 29 RITUXAN, 29 SABRIL, 59 SANCUSO, 29 SANDIMMUNE, 29 SANDOSTATIN LAR, 60 SILDENAFIL, 56 SIMULECT, 29 SOLU-CORTEF, 29 SOMATULINE DEPOT, 29 SOMAVERT, 29 SPRYCEL, 61 SULFAMETHOXAZOLE- TRIMETHOPRIM, 29 SUTENT, 62 SYNRIBO, 29 TACROLIMUS, 29 TARCEVA, 63 TARGRETIN, 64 TASIGNA, 65 TEMAZEPAM, 39 TERBUTALINE SULFATE, 29 TESTOSTERONE CYPIONATE, 30 TESTOSTERONE ENANTHATE, 30 TETANUS DIPHTHERIA TOXOIDS, 30 TETANUS TOXOID ADSORBED, 30 Page 78 of 80

79 TETANUS-DIPHTERIA-DECAVAC, 30 THALOMID, 66 THIORIDAZINE HCL, 67 TOBI, 30 TOBRAMYCIN SULFATE, 30 TOPOSAR, 30 TOPOTECAN HCL, 30 TPN ELECTROLYTES, 30 TRACLEER, 68 TRANEXAMIC ACID, 30 TRANXENE T-TAB, 39 TRAVASOL, 30 TREANDA, 30 TRELSTAR, 30 TRIMETHOBENZAMIDE HCL, 39 TRISENOX, 30 TROPHAMINE, 30 TYKERB, 69 VALPROATE SODIUM, 30 VANCOMYCIN HCL, 30 VELCADE, 30 VERAPAMIL HCL, 30 VFEND IV, 30 VIMPAT, 70 VINBLASTINE SULFATE, 30 VINCRISTINE SULFATE, 30 VINORELBINE TARTRATE, 30 VORAXAZE, 30 VORICONAZOLE, 30 VOTRIENT, 71 VPRIV, 30 XALKORI, 72 XOLAIR, 73 ZALTRAP, 30 ZELBORAF, 74 ZEMPLAR, 30 ZOLEDRONIC ACID, 30 ZOMETA, 30 ZORTRESS, 30 Page 79 of 80

80 HIP Health Plan of New York (HIP) is a Medicare Advantage organization with a Medicare contract. Group Health Incorporated (GHI) is a Medicare Advantage organization and a standalone prescription drug plan with a Medicare contract. HIP and GHI are EmblemHealth companies. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. Beneficiaries must use network pharmacies to access their premium and/or copayment/coinsurance may change on January 1, This document includes EmblemHealth Medicare HMO/PPO partial formulary as of June 1, For a complete, updated formulary, please visit our Web site at or call the Customer Service number below. For alternative formats or language, please call Customer Service toll free at: EmblemHealth Medicare HMO: , Monday through Sunday, 8 am to 8 pm. EmblemHealth Medicare PPO: , Monday through Sunday, 8 am to 8 pm. EmblemHealth Medicare PDP: , Monday through Sunday, 8 am to 8 pm. TTY/TDD users should call v17 Page 80 of 80